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Laakso SM, Häkkinen A, Mäkitie O, Laakso S. Neurological Diseases and Prevalence of Antineuronal Antibodies in Patients with Autoimmune Polyendocrine Syndrome Type 1 - A National Cohort Study. J Clin Immunol 2024; 44:140. [PMID: 38829425 PMCID: PMC11147840 DOI: 10.1007/s10875-024-01748-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Accepted: 05/30/2024] [Indexed: 06/05/2024]
Abstract
Autoimmune polyendocrine syndrome type 1 (APS-1) is a rare monogenic disease caused by mutations in the autoimmune regulator gene. Although the disease-associated autoantibodies mostly target endocrine organs, autoantibodies from patients with APS-1 bind also to rat brain structures. The patients often have GAD65-antibodies, that can cause autoimmune encephalitis. However, neurological manifestations of APS-1 have not been systematically explored. We conducted a retrospective chart review on 44 Finnish patients with APS-1 (median age 38 years, 61% females) and collected all their neurological diagnoses. To assess the prevalence of serum antineuronal antibodies in APS-1, serum samples of 24 patients (median age 36 years, 63% females) were analyzed using a fixed cell-based assay. Of the 44 APS-1 patients, 10 (23%) had also received a diagnosis of a neurological disease. Of these neurological comorbidities, migraine (n = 7; 16%), central nervous system infections (n = 3; 7%), and epilepsy (n = 2; 5%) were the most prevalent. Other diagnoses recorded for single patients were axonal sensorimotor polyneuropathy, essential tremor, idiopathic intracranial hypertension, ischemic stroke, and trigeminal neuralgia. Serum antineuronal antibodies were detected in 42% of patients tested (10/24, 50% females, median age 42 years), GAD65 antibodies being the most common finding. Antibodies against glycine and aquaporin 4 were found in low titers. In four patients, relatively high titers of GAD65 antibodies without coexisting type 1 diabetes were found, but none presented with GAD65-encephalitis. Our study suggests an association between APS-1 and neurological disorders, the mechanisms of which are to be further investigated.
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Affiliation(s)
- Sini M Laakso
- Translational Immunology Research Program, University of Helsinki, Helsinki, Finland.
- Brain Center, Helsinki University Hospital, Helsinki, Finland.
| | - Aino Häkkinen
- Children's Hospital and Pediatric Research Center, Helsinki University Hospital, Helsinki, Finland
- Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Outi Mäkitie
- Children's Hospital and Pediatric Research Center, Helsinki University Hospital, Helsinki, Finland
- Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, Helsinki, Finland
- Folkhälsan Research Center, Helsinki, Finland
- Department of Molecular Medicine and Surgery, Karolinska Institutet and Clinical Genetics, Karolinska University Hospital, Stockholm, Sweden
| | - Saila Laakso
- Children's Hospital and Pediatric Research Center, Helsinki University Hospital, Helsinki, Finland
- Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, Helsinki, Finland
- Folkhälsan Research Center, Helsinki, Finland
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Manto M, Hadjivassiliou M, Baizabal-Carvallo JF, Hampe CS, Honnorat J, Joubert B, Mitoma H, Muñiz-Castrillo S, Shaikh AG, Vogrig A. Consensus Paper: Latent Autoimmune Cerebellar Ataxia (LACA). CEREBELLUM (LONDON, ENGLAND) 2024; 23:838-855. [PMID: 36991252 PMCID: PMC10060034 DOI: 10.1007/s12311-023-01550-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/20/2023] [Indexed: 06/01/2023]
Abstract
Immune-mediated cerebellar ataxias (IMCAs) have diverse etiologies. Patients with IMCAs develop cerebellar symptoms, characterized mainly by gait ataxia, showing an acute or subacute clinical course. We present a novel concept of latent autoimmune cerebellar ataxia (LACA), analogous to latent autoimmune diabetes in adults (LADA). LADA is a slowly progressive form of autoimmune diabetes where patients are often initially diagnosed with type 2 diabetes. The sole biomarker (serum anti-GAD antibody) is not always present or can fluctuate. However, the disease progresses to pancreatic beta-cell failure and insulin dependency within about 5 years. Due to the unclear autoimmune profile, clinicians often struggle to reach an early diagnosis during the period when insulin production is not severely compromised. LACA is also characterized by a slowly progressive course, lack of obvious autoimmune background, and difficulties in reaching a diagnosis in the absence of clear markers for IMCAs. The authors discuss two aspects of LACA: (1) the not manifestly evident autoimmunity and (2) the prodromal stage of IMCA's characterized by a period of partial neuronal dysfunction where non-specific symptoms may occur. In order to achieve an early intervention and prevent cell death in the cerebellum, identification of the time-window before irreversible neuronal loss is critical. LACA occurs during this time-window when possible preservation of neural plasticity exists. Efforts should be devoted to the early identification of biological, neurophysiological, neuropsychological, morphological (brain morphometry), and multimodal biomarkers allowing early diagnosis and therapeutic intervention and to avoid irreversible neuronal loss.
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Affiliation(s)
- Mario Manto
- Service de Neurologie, Médiathèque Jean Jacquy, CHU-Charleroi, Charleroi, Belgium
- Service des Neurosciences, University of Mons, Mons, Belgium
| | | | | | | | - Jerome Honnorat
- French Reference Center on Paraneoplastic Neurological Syndromes, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
- Institut NeuroMyoGene MELIS INSERM U1314/CNRS UMR 5284, Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Bastien Joubert
- French Reference Center on Paraneoplastic Neurological Syndromes, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
- Institut NeuroMyoGene MELIS INSERM U1314/CNRS UMR 5284, Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Hiroshi Mitoma
- Department of Medical Education, Tokyo Medical University, Tokyo, Japan.
| | | | - Aasef G Shaikh
- Louis Stokes Cleveland VA Medical Center, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Alberto Vogrig
- Clinical Neurology, Udine University Hospital, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC), Udine, Italy
- Department of Medicine (DAME), University of Udine, Udine, Italy
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Hampe CS, Shojaie A, Brooks-Worrell B, Dibay S, Utzschneider K, Kahn SE, Larkin ME, Johnson ML, Younes N, Rasouli N, Desouza C, Cohen RM, Park JY, Florez HJ, Valencia WM, Palmer JP, Balasubramanyam A. GAD65Abs Are Not Associated With Beta-Cell Dysfunction in Patients With T2D in the GRADE Study. J Endocr Soc 2024; 8:bvad179. [PMID: 38333889 PMCID: PMC10853002 DOI: 10.1210/jendso/bvad179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Indexed: 02/10/2024] Open
Abstract
Context Autoantibodies directed against the 65-kilodalton isoform of glutamic acid decarboxylase (GAD65Abs) are markers of autoimmune type 1 diabetes (T1D) but are also present in patients with Latent Autoimmune Diabetes of Adults and autoimmune neuromuscular diseases, and also in healthy individuals. Phenotypic differences between these conditions are reflected in epitope-specific GAD65Abs and anti-idiotypic antibodies (anti-Id) against GAD65Abs. We previously reported that 7.8% of T2D patients in the GRADE study have GAD65Abs but found that GAD65Ab positivity was not correlated with beta-cell function, glycated hemoglobin (HbA1c), or fasting glucose levels. Context In this study, we aimed to better characterize islet autoantibodies in this T2D cohort. This is an ancillary study to NCT01794143. Methods We stringently defined GAD65Ab positivity with a competition assay, analyzed GAD65Ab-specific epitopes, and measured GAD65Ab-specific anti-Id in serum. Results Competition assays confirmed that 5.9% of the patients were GAD65Ab positive, but beta-cell function was not associated with GAD65Ab positivity, GAD65Ab epitope specificity or GAD65Ab-specific anti-Id. GAD65-related autoantibody responses in GRADE T2D patients resemble profiles in healthy individuals (low GAD65Ab titers, presence of a single autoantibody, lack of a distinct epitope pattern, and presence of anti-Id to diabetes-associated GAD65Ab). In this T2D cohort, GAD65Ab positivity is likely unrelated to the pathogenesis of beta-cell dysfunction. Conclusion Evidence for islet autoimmunity in the pathophysiology of T2D beta-cell dysfunction is growing, but T1D-associated autoantibodies may not accurately reflect the nature of their autoimmune process.
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Affiliation(s)
| | - Ali Shojaie
- Department of Biostatistics, Department of Medicine, University of Washington, Seattle, WA 98185, USA
| | - Barbara Brooks-Worrell
- Department of Biostatistics, Department of Medicine, University of Washington, Seattle, WA 98185, USA
- Department of Medicine, VA Puget Sound Health Care System, Seattle, WA 98108, USA
| | - Sepideh Dibay
- Department of Biostatistics, Department of Medicine, University of Washington, Seattle, WA 98185, USA
| | - Kristina Utzschneider
- Department of Biostatistics, Department of Medicine, University of Washington, Seattle, WA 98185, USA
- Department of Medicine, VA Puget Sound Health Care System, Seattle, WA 98108, USA
| | - Steven E Kahn
- Department of Biostatistics, Department of Medicine, University of Washington, Seattle, WA 98185, USA
- Department of Medicine, VA Puget Sound Health Care System, Seattle, WA 98108, USA
| | - Mary E Larkin
- Massachusetts General Hospital Diabetes Center, Harvard Medical School, Boston, MA 02114, USA
| | - Mary L Johnson
- International Diabetes Center, Minneapolis, MN 55416, USA
| | - Naji Younes
- The Biostatistics Center, Department of Biostatistics and Bioinformatics, Milken Institute School of Public Health, The George Washington University, Rockville, MD 20852, USA
| | - Neda Rasouli
- Department of Medicine, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Cyrus Desouza
- Division of Diabetes, Endocrinology and Metabolism, University of Nebraska and Omaha VA Medical Center, Omaha, NE 68198, USA
| | - Robert M Cohen
- Division of Endocrinology, Diabetes and Metabolism, University of Cincinnati and Cincinnati VA Medical Center, Cincinnati, OH 45221, USA
| | | | - Hermes J Florez
- Department of Medicine, University of Miami, Miami, FL 33135, USA
- Division of Endocrinology, Diabetes and Metabolic Diseases, Medical University of South Carolina, Charleston, SC 29425, USA
| | - Willy Marcos Valencia
- Division of Endocrinology, Diabetes and Metabolic Diseases, Medical University of South Carolina, Charleston, SC 29425, USA
- Geriatric Research, Education and Clinical Center, Bruce W. Carter Veterans Affairs Medical Center, Miami, FL 33125, USA
- Robert Stempel Department of Public Health, College of Health and Urban Affairs, Florida International University, Miami, FL 33181, USA
| | - Jerry P Palmer
- Department of Biostatistics, Department of Medicine, University of Washington, Seattle, WA 98185, USA
- Department of Medicine, VA Puget Sound Health Care System, Seattle, WA 98108, USA
| | - Ashok Balasubramanyam
- Department of Medicine: Endocrinology, Diabetes and Metabolism, Baylor College of Medicine, Houston, TX 77030, USA
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Vlad B, Wang Y, Newsome SD, Balint B. Stiff Person Spectrum Disorders-An Update and Outlook on Clinical, Pathophysiological and Treatment Perspectives. Biomedicines 2023; 11:2500. [PMID: 37760941 PMCID: PMC10525659 DOI: 10.3390/biomedicines11092500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 09/06/2023] [Accepted: 09/07/2023] [Indexed: 09/29/2023] Open
Abstract
Stiff person spectrum disorders (SPSD) are paradigm autoimmune movement disorders characterized by stiffness, spasms and hyperekplexia. Though rare, SPSD represent a not-to-miss diagnosis because of the associated disease burden and treatment implications. After decades as an enigmatic orphan disease, major advances in our understanding of the evolving spectrum of diseases have been made along with the identification of multiple associated autoantibodies. However, the most important recent developments relate to the recognition of a wider affection, beyond the classic core motor symptoms, and to further insights into immunomodulatory and symptomatic therapies. In this review, we summarize the recent literature on the clinical and paraclinical spectrum, current pathophysiological understanding, as well as current and possibly future therapeutic strategies.
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Affiliation(s)
- Benjamin Vlad
- Department of Neurology, University Hospital Zurich, 8091 Zurich, Switzerland;
| | - Yujie Wang
- Department of Neurology, University of Washington, Seattle, WA 98195, USA
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Scott D. Newsome
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Bettina Balint
- Department of Neurology, University Hospital Zurich, 8091 Zurich, Switzerland;
- Faculty of Medicine, University of Zurich, 8091 Zurich, Switzerland
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Zong S, Vinke AM, Du P, Hoffmann C, Mané-Damas M, Molenaar PC, Damoiseaux JGMC, Losen M, Rouhl RPW, Martinez-Martinez P. Anti-GAD65 autoantibody levels measured by ELISA and alternative types of immunoassays in relation to neuropsychiatric diseases versus diabetes mellitus type 1. Front Neurol 2023; 14:1111063. [PMID: 37305746 PMCID: PMC10248002 DOI: 10.3389/fneur.2023.1111063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 05/10/2023] [Indexed: 06/13/2023] Open
Abstract
Background Anti-GAD65 autoantibodies (GAD65-Abs) may occur in patients with epilepsy and other neurological disorders, but the clinical significance is not clear-cut. Whereas high levels of GAD65-Abs are considered pathogenic in neuropsychiatric disorders, low or moderate levels are only considered as mere bystanders in, e.g., diabetes mellitus type 1 (DM1). The value of cell-based assays (CBA) and immunohistochemistry (IHC) for GAD65-Abs detection has not been clearly evaluated in this context. Objective To re-evaluate the assumption that high levels of GAD65-Abs are related to neuropsychiatric disorders and lower levels only to DM1 and to compare ELISA results with CBA and IHC to determine the additional value of these tests. Methods 111 sera previously assessed for GAD65-Abs by ELISA in routine clinical practice were studied. Clinical indications for testing were, e.g., suspected autoimmune encephalitis or epilepsy (neuropsychiatric cohort; n = 71, 7 cases were initially tested positive for GAD65-Abs by ELISA), and DM1 or latent autoimmune diabetes in adults (DM1/LADA cohort (n = 40, all were initially tested positive)). Sera were re-tested for GAD65-Abs by ELISA, CBA, and IHC. Also, we examined the possible presence of GAD67-Abs by CBA and of other neuronal autoantibodies by IHC. Samples that showed IHC patterns different from GAD65 were further tested by selected CBAs. Results ELISA retested GAD65-Abs level in patients with neuropsychiatric diseases was higher than in patients with DM1/LADA (only retested positive samples were compared; 6 vs. 38; median 47,092 U/mL vs. 581 U/mL; p = 0.02). GAD-Abs showed positive both by CBA and IHC only if antibody levels were above 10,000 U/mL, without a difference in prevalence between the studied cohorts. We found other neuronal antibodies in one patient with epilepsy (mGluR1-Abs, GAD-Abs negative), and in a patient with encephalitis, and two patients with LADA. Conclusion GAD65-Abs levels are significantly higher in patients with neuropsychiatric disease than in patients with DM1/LADA, however, positivity in CBA and IHC only correlates with high levels of GAD65-Abs, and not with the underlying diseases.
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Affiliation(s)
- Shenghua Zong
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience (MHeNS), Maastricht University, Maastricht, Netherlands
| | - Anita M. Vinke
- Department of Neurology, Maastricht University Medical Center (MUMC +), Maastricht, Netherlands
| | - Peng Du
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience (MHeNS), Maastricht University, Maastricht, Netherlands
| | - Carolin Hoffmann
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience (MHeNS), Maastricht University, Maastricht, Netherlands
- Algarve Biomedical Center, Algarve Biomedical Center Research Institute, Faro, Portugal
| | - Marina Mané-Damas
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience (MHeNS), Maastricht University, Maastricht, Netherlands
| | - Peter C. Molenaar
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience (MHeNS), Maastricht University, Maastricht, Netherlands
| | | | - Mario Losen
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience (MHeNS), Maastricht University, Maastricht, Netherlands
| | - Rob P. W. Rouhl
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience (MHeNS), Maastricht University, Maastricht, Netherlands
- Department of Neurology, Maastricht University Medical Center (MUMC +), Maastricht, Netherlands
- Academic Centre for Epileptology Kempenhaeghe/MUMC+, Maastricht, Netherlands
| | - Pilar Martinez-Martinez
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience (MHeNS), Maastricht University, Maastricht, Netherlands
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Bartley CM, Ngo TT, Cadwell CR, Harroud A, Schubert RD, Alvarenga BD, Hawes IA, Zorn KC, Hunyh T, Teliska LH, Kung AF, Shah S, Gelfand JM, Chow FC, Rasband MN, Dubey D, Pittock SJ, DeRisi JL, Wilson MR, Pleasure SJ. Dual ankyrinG and subpial autoantibodies in a man with well-controlled HIV infection with steroid-responsive meningoencephalitis: A case report. Front Neurol 2023; 13:1102484. [PMID: 36756346 PMCID: PMC9900111 DOI: 10.3389/fneur.2022.1102484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 12/16/2022] [Indexed: 01/24/2023] Open
Abstract
Neuroinvasive infection is the most common cause of meningoencephalitis in people living with human immunodeficiency virus (HIV), but autoimmune etiologies have been reported. We present the case of a 51-year-old man living with HIV infection with steroid-responsive meningoencephalitis whose comprehensive pathogen testing was non-diagnostic. Subsequent tissue-based immunofluorescence with acute-phase cerebrospinal fluid revealed anti-neural antibodies localizing to the axon initial segment (AIS), the node of Ranvier (NoR), and the subpial space. Phage display immunoprecipitation sequencing identified ankyrinG (AnkG) as the leading candidate autoantigen. A synthetic blocking peptide encoding the PhIP-Seq-identified AnkG epitope neutralized CSF IgG binding to the AIS and NoR, thereby confirming a monoepitopic AnkG antibody response. However, subpial immunostaining persisted, indicating the presence of additional autoantibodies. Review of archival tissue-based staining identified candidate AnkG autoantibodies in a 60-year-old woman with metastatic ovarian cancer and seizures that were subsequently validated by cell-based assay. AnkG antibodies were not detected by tissue-based assay and/or PhIP-Seq in control CSF (N = 39), HIV CSF (N = 79), or other suspected and confirmed neuroinflammatory CSF cases (N = 1,236). Therefore, AnkG autoantibodies in CSF are rare but extend the catalog of AIS and NoR autoantibodies associated with neurological autoimmunity.
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Affiliation(s)
- Christopher M. Bartley
- Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, United States
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, San Francisco, CA, United States
| | - Thomas T. Ngo
- Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, United States
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, San Francisco, CA, United States
| | - Cathryn R. Cadwell
- Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, United States
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, United States
- Department of Pathology, University of California, San Francisco, San Francisco, CA, United States
| | - Adil Harroud
- Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, United States
- Department of Neurology, University of California, San Francisco, San Francisco, CA, United States
| | - Ryan D. Schubert
- Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, United States
- Department of Neurology, University of California, San Francisco, San Francisco, CA, United States
| | - Bonny D. Alvarenga
- Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, United States
- Department of Neurology, University of California, San Francisco, San Francisco, CA, United States
| | - Isobel A. Hawes
- Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, United States
- Department of Neurology, University of California, San Francisco, San Francisco, CA, United States
- Biomedical Sciences Graduate Program, University of California, San Francisco, San Francisco, CA, United States
| | - Kelsey C. Zorn
- Department of Biochemistry and Biophysics, University of California, San Francisco, San Francisco, CA, United States
| | - Trung Hunyh
- Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, United States
- Department of Neurology, University of California, San Francisco, San Francisco, CA, United States
| | - Lindsay H. Teliska
- Department of Neuroscience, Baylor College of Medicine, Houston, TX, United States
| | - Andrew F. Kung
- School of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Shailee Shah
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, United States
- Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic, Rochester, MN, United States
| | - Jeffrey M. Gelfand
- Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, United States
- Department of Neurology, University of California, San Francisco, San Francisco, CA, United States
| | - Felicia C. Chow
- Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, United States
- Department of Neurology, University of California, San Francisco, San Francisco, CA, United States
| | - Matthew N. Rasband
- Department of Neuroscience, Baylor College of Medicine, Houston, TX, United States
| | - Divyanshu Dubey
- Department of Neurology, Mayo Clinic Foundation, Rochester, MN, United States
- Department of Laboratory Medicine and Pathology, Mayo Clinic Foundation, Rochester, MN, United States
| | - Sean J. Pittock
- Center for Multiple Sclerosis and Autoimmune Neurology, Mayo Clinic, Rochester, MN, United States
- Department of Neurology, Mayo Clinic Foundation, Rochester, MN, United States
- Department of Laboratory Medicine and Pathology, Mayo Clinic Foundation, Rochester, MN, United States
| | - Joseph L. DeRisi
- Department of Biochemistry and Biophysics, University of California, San Francisco, San Francisco, CA, United States
- Chan Zuckerberg Biohub, San Francisco, CA, United States
| | - Michael R. Wilson
- Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, United States
- Department of Neurology, University of California, San Francisco, San Francisco, CA, United States
| | - Samuel J. Pleasure
- Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, United States
- Department of Neurology, University of California, San Francisco, San Francisco, CA, United States
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Sun H, Ma D, Cheng Y, Li J, Zhang W, Jiang T, Li Z, Li X, Meng H. The JAK-STAT Signaling Pathway in Epilepsy. Curr Neuropharmacol 2023; 21:2049-2069. [PMID: 36518035 PMCID: PMC10556373 DOI: 10.2174/1570159x21666221214170234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 11/08/2022] [Accepted: 11/21/2022] [Indexed: 12/16/2022] Open
Abstract
Epilepsy is defined as spontaneous recurrent seizures in the brain. There is increasing evidence that inflammatory mediators and immune cells are involved in epileptic seizures. As more research is done on inflammatory factors and immune cells in epilepsy, new targets for the treatment of epilepsy will be revealed. The Janus kinase-signal transducer and transcriptional activator (JAKSTAT) signaling pathway is strongly associated with many immune and inflammatory diseases, At present, more and more studies have found that the JAK-STAT pathway is involved in the development and development of epilepsy, indicating the JAK-STAT pathway's potential promise as a target in epilepsy treatment. In this review, we discuss the composition, activation, and regulation of the JAK-STAT pathway and the relationship between the JAK-STAT pathway and epilepsy. In addition, we summarize the common clinical inhibitors of JAK and STAT that we would expect to be used in epilepsy treatment in the future.
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Affiliation(s)
- Huaiyu Sun
- Department of Neurology and Neuroscience Center, The First Hospital of Jilin University, Changchun, China
| | - Di Ma
- Department of Neurology and Neuroscience Center, The First Hospital of Jilin University, Changchun, China
| | - Yu Cheng
- Department of Neurology and Neuroscience Center, The First Hospital of Jilin University, Changchun, China
| | - Jiaai Li
- Department of Neurology and Neuroscience Center, The First Hospital of Jilin University, Changchun, China
| | - Wuqiong Zhang
- Department of Neurology and Neuroscience Center, The First Hospital of Jilin University, Changchun, China
| | - Ting Jiang
- Department of Neurology and Neuroscience Center, The First Hospital of Jilin University, Changchun, China
| | - Zhaoran Li
- Department of Neurology and Neuroscience Center, The First Hospital of Jilin University, Changchun, China
| | - Xuewei Li
- Department of Radiology, The First Hospital of Jilin University, Changchun, China
| | - Hongmei Meng
- Department of Neurology and Neuroscience Center, The First Hospital of Jilin University, Changchun, China
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Rácz A, Hummel CA, Becker A, Helmstaedter C, Schuch F, Baumgartner T, von Wrede R, Borger V, Solymosi L, Surges R, Elger CE. Histopathologic Characterization and Neurodegenerative Markers in Patients With Limbic Encephalitis Undergoing Epilepsy Surgery. Front Neurol 2022; 13:859868. [PMID: 35493848 PMCID: PMC9051082 DOI: 10.3389/fneur.2022.859868] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 03/09/2022] [Indexed: 11/19/2022] Open
Abstract
Purpose Limbic encephalitis is an increasingly recognized cause of medial temporal lobe epilepsy (mTLE) and associated cognitive deficits, potentially resulting in hippocampal sclerosis (HS). For several reasons, these patients usually do not undergo epilepsy surgery. Thus, histopathologic examinations in surgical specimens of clearly diagnosed limbic encephalitis are scarce. The purpose of this study was a detailed histopathologic analysis of surgical tissue alterations, including neurodegenerative markers, in patients with limbic encephalitis undergoing epilepsy surgery. Methods We investigated the surgical specimens of six patients operated on with mTLE related to limbic encephalitis (among them four patients were with GAD65 and one with Ma1/2 antibodies), and compared the findings to a control group with six patients matched according to age at the time of surgery without limbic encephalitis and without early inciting events. Results Histopathologic analysis in the group with limbic encephalitis revealed HS in four patients, while three of them also displayed signs of an active inflammatory reaction with lymphocytes. In one of the patients with GAD65-encephalitis who was suffering from a late-onset mTLE and a long disease course, neurodegenerative protein markers (β-amyloid and hyperphosphorylated tau) were found coexisting with inflammatory reactions and HS. Investigations in the control group did not reveal any inflammatory reaction or neurodegenerative marker. Conclusion Our findings suggest a possible link between long-lasting immune reactions in the medial temporal lobe, HS, and further toward the development of neurodegenerative diseases. Presently, however, a causal relationship between these entities cannot yet be established. Furthermore, our results suggest that an immunological etiology should always be considered in late onset (> 18 years) mTLE, also in cases of long disease duration and the presence of HS.
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Affiliation(s)
- Attila Rácz
- Department of Epileptology, University Hospital Bonn, Bonn, Germany
- *Correspondence: Attila Rácz
| | - Chiara A. Hummel
- Department of Neuropathology, University Hospital Bonn, Bonn, Germany
| | - Albert Becker
- Department of Neuropathology, University Hospital Bonn, Bonn, Germany
| | | | - Fabiane Schuch
- Department of Epileptology, University Hospital Bonn, Bonn, Germany
| | | | - Randi von Wrede
- Department of Epileptology, University Hospital Bonn, Bonn, Germany
| | - Valeri Borger
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
| | - László Solymosi
- Department of Neuroradiology, University Hospital Bonn, Bonn, Germany
| | - Rainer Surges
- Department of Epileptology, University Hospital Bonn, Bonn, Germany
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Madkhali MA, Hao JK, Khan MS, Sharma H, Jaume A, Tiwari A, Imam S, Jaume JC. Intractable Seizures and Limbic Encephalitis, Unaccounted Complications of Type 1 Diabetes Autoimmunity. J Endocr Soc 2022; 6:bvab188. [PMID: 35128296 PMCID: PMC8807154 DOI: 10.1210/jendso/bvab188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Indexed: 11/20/2022] Open
Abstract
Glutamic acid decarboxylase 65kD autoantibody (GAD65Ab) is frequently detected in patients with refractory epilepsy and stiff person syndrome. In contrast to T1D, the pathological role of GAD65Ab in neurological disorders is still debatable. As a result, the implementation of possible immunotherapy is usually delayed. This report presents 2 cases of GAD65Ab-associated brain autoimmunity and their different management. We present clinical data and discuss management based on available evidence in the reviewed literature. Both cases presented with acute on chronic neurological symptoms and were GAD65Ab positive. Case 1, a 30-year-old man with a history of early-onset type 1 diabetes mellitus at 14 months, followed by cryptogenic temporal epilepsy at 11 years of age, presented with intractable seizures. Case 2, a 48-year-old woman, presented with a history of recurrent severe headaches, cognitive impairment, decreased memory, and behavioral symptoms. GAD65Ab was detected in both patients’ sera. Cerebrospinal fluid GAD65Ab was only checked and positive in case 1. Case 2 was diagnosed with limbic encephalitis, treated with immunotherapy, and showed a remarkable clinical improvement. Case 1 with refractory epilepsy failed multiple antiepileptic drugs and responsive-stimulator system treatments. He was finally diagnosed with autoimmune epilepsy. The delay in diagnosis resulted in a lost opportunity for early immunotherapy. In conclusion, autoantibody screening and early initiation of immunotherapy should be considered to manage GAD65Ab-associated neurological disorders.
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Affiliation(s)
- Mohammed A Madkhali
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism and Center for Diabetes and Endocrine Research (CeDER), College of Medicine and Life Sciences (formerly Medical College of Ohio), University of Toledo, Toledo, Ohio, USA
- Department of Internal Medicine, Division of Endocrinology, Faculty of Medicine, Jazan University, Jazan, Jizan, Saudi Arabia
| | - Jenifer-Kris Hao
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism and Center for Diabetes and Endocrine Research (CeDER), College of Medicine and Life Sciences (formerly Medical College of Ohio), University of Toledo, Toledo, Ohio, USA
| | - Mohammad Saud Khan
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism and Center for Diabetes and Endocrine Research (CeDER), College of Medicine and Life Sciences (formerly Medical College of Ohio), University of Toledo, Toledo, Ohio, USA
- Department of Cardiology, University of Kentucky at Bowling Green, Bowling Green, KY
| | - Himani Sharma
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism and Center for Diabetes and Endocrine Research (CeDER), College of Medicine and Life Sciences (formerly Medical College of Ohio), University of Toledo, Toledo, Ohio, USA
| | - Alexa Jaume
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism and Center for Diabetes and Endocrine Research (CeDER), College of Medicine and Life Sciences (formerly Medical College of Ohio), University of Toledo, Toledo, Ohio, USA
| | - Abhinav Tiwari
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism and Center for Diabetes and Endocrine Research (CeDER), College of Medicine and Life Sciences (formerly Medical College of Ohio), University of Toledo, Toledo, Ohio, USA
| | - Shahnawaz Imam
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism and Center for Diabetes and Endocrine Research (CeDER), College of Medicine and Life Sciences (formerly Medical College of Ohio), University of Toledo, Toledo, Ohio, USA
| | - Juan Carlos Jaume
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism and Center for Diabetes and Endocrine Research (CeDER), College of Medicine and Life Sciences (formerly Medical College of Ohio), University of Toledo, Toledo, Ohio, USA
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Tsiortou P, Alexopoulos H, Dalakas MC. GAD antibody-spectrum disorders: progress in clinical phenotypes, immunopathogenesis and therapeutic interventions. Ther Adv Neurol Disord 2021; 14:17562864211003486. [PMID: 33854562 PMCID: PMC8013924 DOI: 10.1177/17562864211003486] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 02/27/2021] [Indexed: 12/14/2022] Open
Abstract
Antibodies against glutamic acid decarboxylase (GAD), originally linked to stiff person syndrome (SPS), now denote the "GAD antibody-spectrum disorders" (GAD-SD) that also include autoimmune epilepsy, limbic encephalitis, cerebellar ataxia and nystagmus with overlapping symptomatology highlighting autoimmune neuronal excitability disorders. The reasons for the clinical heterogeneity among GAD-antibody associated syndromes remain still unsettled, implicating variable susceptibility of GABAergic neurons to anti-GAD or other still unidentified autoantibodies. Although anti-GAD antibody titers do not correlate with clinical severity, very high serum titers, often associated with intrathecal synthesis of anti-GAD-specific IgG, point to in-situ effects of GAD or related autoantibodies within the central nervous system. It remains, however, uncertain what drives these antibodies, why they persist and whether they are disease markers or have pathogenic potential. The review, focused on these concerns, describes the widened clinical manifestations and overlapping features of all GAD-SD; addresses the importance of GAD antibody titers and potential significance of GAD epitopes; summarizes the biologic basis of autoimmune hyperexcitability; highlights the electrophysiological basis of reciprocal inhibition in muscle stiffness; and provides practical guidelines on symptomatic therapies with gamma-aminobutyric acid-enhancing drugs or various immunotherapies.
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Affiliation(s)
- Popianna Tsiortou
- Neuroimmunology Unit, Department of Pathophysiology, Faculty of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Harry Alexopoulos
- Neuroimmunology Unit, Department of Pathophysiology, Faculty of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Marinos C Dalakas
- Department of Neurology, Thomas Jefferson University, 900 Walnut Street, Philadelphia, PA 19107, USA; Neuroimmunology Unit, National and Kapodistrian University of Athens, Athens, Greece
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11
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Wen S, Jiang W, Zhou L. Islet Autoantibodies in the Patients with Sjogren's Syndrome and Thyroid Disease and Risk of Progression to Latent Autoimmune Diabetes in Adults: A Case Series. Diabetes Metab Syndr Obes 2021; 14:1025-1033. [PMID: 33707961 PMCID: PMC7943329 DOI: 10.2147/dmso.s295847] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Accepted: 02/22/2021] [Indexed: 12/17/2022] Open
Abstract
The glutamic acid decarboxylase 65 antibody (GAD65-Ab) is an autoimmune marker in some diseases such as diabetes or autoimmune disorders of the central nervous system such as stiff-man syndrome. It can appear with other pancreatic autoantibodies, such as insulin autoantibodies (IAA), presenting as early signs of pancreatic islet β-cells impairing, and play roles in the pathogenesis of type1 diabetes (T1D) and latent autoimmune diabetes in adults (LADA). Positive GAD65-Ab is rarely observed in insulin-dependent diabetic patients with other acquired autoimmune diseases, such as Sjogren's syndrome (SS). Besides, LADA revealed by islet autoantibodies such as GAD65-Ab can also be complicated with Hashimoto's thyroiditis (HT), another autoimmune thyroid disease. To date, whether GAD65-Ab positive in patients with autoimmune diseases predicts the onset or progression to T1D or LADA remains unknown. Herein, two unique cases of middle-aged Chinese Han women free from diabetes for three years are described despite their blood tests persistently testing positive for GAD65-Ab or IAA. Both patients suffered from HT and SS. Follow-up OGTTs (oral glucose tolerance test) for three years revealed that the patients had a well-controlled glycemic level and normal pancreatic function. However, one of the patients had a temporary increase of postprandial glucose after a short-term loss of diet control. The presence of auto-immune antibodies in these patients had little impact on glucose tolerance or insulin secretion in 3 years. The study postulate that both the primary immune injury caused by serum GAD65-Ab positive, an autoimmune marker, and increased body weight contribute to the progression of LADA.
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Affiliation(s)
- Song Wen
- Department of Endocrinology, Shanghai Pudong Hospital, Fudan University, Shanghai, 201399, People’s Republic of China
| | - Wenjing Jiang
- Department of Endocrinology, Shanghai Pudong Hospital, Fudan University, Shanghai, 201399, People’s Republic of China
| | - Ligang Zhou
- Department of Endocrinology, Shanghai Pudong Hospital, Fudan University, Shanghai, 201399, People’s Republic of China
- Correspondence: Ligang Zhou Department of Endocrinology, Shanghai Pudong Hospital, Fudan University, Shanghai, 201399, People’s Republic of ChinaTel +8613611927616 Email
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12
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Paredes-Aragón EM, Valdéz-Ruvalcaba HE, Santos-Peyret A, Cisneros-Otero M, Medina-Rioja R, Orozco-Suárez S, Hernandez MM, Breda-Yepes MDL, Rivas-Alonso V, Flores-Rivera JJ, Martínez-Juárez IE. Continuous Visual Focal Status Epilepticus as the Primary Presentation of NMDA-R and GAD65-R Autoimmune Epilepsy. Front Neurol 2020; 11:598974. [PMID: 33324338 PMCID: PMC7726346 DOI: 10.3389/fneur.2020.598974] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 10/21/2020] [Indexed: 11/15/2022] Open
Abstract
Epilepsia partialis continua (EPC) has changed in its clinical and pathophysiological definition throughout time. Several etiologies have been described in addition to classic causes of EPC. The following case depicts a young woman who had a peculiar onset of epilepsy with a continuous visual aura becoming a form of chronic recurrent and non-progressive EPC. The patient was initially misdiagnosed as a non-neurological entity (assumed psychiatric in origin), but finally, an immune-mediated epilepsy was diagnosed, and EEG showed focal status epilepticus during evolution. Once the diagnosis was achieved and immune treatment was established, the patient is seizure free. Early identification of an immune basis in patients with epilepsy is important because immunotherapy can reverse the epileptogenic process and reduce the risk of chronic epilepsy. To date, this is the only case reported with EPC manifesting as a continuous visual aura associated with antiglutamic acid decarboxylase 65 (anti-GAD65) and anti-N-methyl-d-aspartate (anti-NMDA) antibodies.
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Affiliation(s)
- Elma M Paredes-Aragón
- Epilepsy Clinic, National Institute of Neurology and Neurosurgery, Mexico City, Mexico
| | | | - Andrea Santos-Peyret
- Epilepsy Clinic, National Institute of Neurology and Neurosurgery, Mexico City, Mexico
| | - Marcela Cisneros-Otero
- Neuropsychiatry Clinic, National Institute of Neurology and Neurosurgery, Mexico City, Mexico
| | - Raúl Medina-Rioja
- Neurology Clinic, National Institute of Neurology and Neurosurgery, Mexico City, Mexico
| | - Sandra Orozco-Suárez
- Unit of Medical Research in Neurologic Diseases (UIMEN), Medical National Center Century XXI, Mexican Institute of Social Security, Mexico City, Mexico
| | - Miriam M Hernandez
- Neurology Clinic, National Institute of Neurology and Neurosurgery, Mexico City, Mexico
| | | | - Verónica Rivas-Alonso
- Neuroimmunology Clinic, National Institute of Neurology and Neurosurgery, Mexico City, Mexico
| | - José J Flores-Rivera
- Neuroimmunology Clinic, National Institute of Neurology and Neurosurgery, Mexico City, Mexico
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13
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Sharp CN, Fletcher A, Muluhngwi P, Snyder J, Linder MW, Jortani SA. A Shared Diagnostic Stewardship Approach toward Improving Autoimmune Encephalopathy Send-out Testing Utilization. J Appl Lab Med 2020; 6:387-396. [PMID: 33674881 DOI: 10.1093/jalm/jfaa123] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 06/24/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND For many laboratories, autoimmune encephalopathy (AE) panels are send-out tests. These tests are expensive, and ordering patterns vary greatly. There is also a lack of consensus on which panel to order and poor understanding of the clinical utility of these panels. These challenges were presented to our newly formed, multidisciplinary, diagnostic stewardship committee (DSC). Through this collaboration, we developed an algorithm for ordering AE panels; combining diagnostic criteria with practice guidelines. METHODS We analyzed test-ordering patterns in 2018 and calculated a true-positive rate based on clinical presentation and panel interpretation. An evidence-based approach was combined with input from the Department of Neurology to synthesize our algorithm. Efficacy of the algorithm (number of panels ordered, cost, and true positives) was assessed before and after implementation. RESULTS In 2018, 77 AE-related panels were ordered, costing $137 510. The true-positive rate was 10%, although ordering multiple, similar panels for the same patient was common. Before implementing the algorithm (January 1-July 31, 2019), 55 panels were ordered, costing $105 120. The total true-positive rate was 3.6%. After implementation, 23 tests were ordered in a 5-month period, totaling $50 220. The true-positive rate was 13%. CONCLUSION With the DSC-directed mandate, we developed an algorithm for ordering AE panels. Comparison of pre- and postimplementation data showed a higher true-positive rate, indicating that our algorithm was able to successfully identify the at-risk population for AE disorders. This was met with a 43% decrease in the number of tests ordered, with total cost savings of $25 000 over 5 months.
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Affiliation(s)
- Cierra N Sharp
- Department of Pathology and Laboratory Medicine, University of Louisville, Louisville, KY
| | - Anita Fletcher
- Department of Neurology, University of Louisville, Louisville, KY
| | - Penn Muluhngwi
- Department of Pathology and Laboratory Medicine, University of Louisville, Louisville, KY
| | - James Snyder
- Department of Pathology and Laboratory Medicine, University of Louisville, Louisville, KY
| | - Mark W Linder
- Department of Pathology and Laboratory Medicine, University of Louisville, Louisville, KY
| | - Saeed A Jortani
- Department of Pathology and Laboratory Medicine, University of Louisville, Louisville, KY
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Zhu F, Shan W, Lv R, Li Z, Wang Q. Clinical characteristics of GAD 65-associated autoimmune encephalitis. Acta Neurol Scand 2020; 142:281-293. [PMID: 32416610 DOI: 10.1111/ane.13281] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 05/11/2020] [Accepted: 05/12/2020] [Indexed: 12/15/2022]
Abstract
OBJECTIVES To examine the clinical characteristics of autoimmune encephalitis associated with the glutamate decarboxylase 65 (GAD 65) antibody. MATERIALS AND METHODS Medical records of all patients that diagnosed with GAD 65 antibody-associated encephalitis were retrospectively analyzed. Data regarding demographics and symptoms, neurological signs, laboratory and imaging results, treatment and prognosis were collected. RESULTS We collected a total of seven patients, mainly young or middle-aged women with a subacute or chronic course. The main clinical symptoms mainly included chronic epilepsy, cerebellar ataxia, stiff-person syndrome, and limbic encephalitis. Three of seven (43%) patients had high CSF (cerebrospinal fluid) protein levels. Oligoclonal IgG bands (including IgG 1) and 24 hours intrathecal synthesis of IgG were detected in CSF and serum in six patients, five patients (83%) reported increased distribution of oligoclonal IgG bands (including IgG 1) and 24 hours intrathecal synthesis of IgG in serum and CSF. And six of seven patients (86%) had abnormal thyroid function or were positive for thyroid antibodies. By electroencephalogram examination, sharp or slow waves in the temporal region were often observed for six of seven patients (86%). Abnormal imaging signals (six of seven patients, 86%) of the temporal lobe and hippocampus were detected by brain magnetic resonance imaging, and decreased metabolism of the temporal lobe was detected by positron emission tomography/computed tomography (six of six patients, 100%). These patients were mainly treated with corticosteroid and gamma globulin. The clinical symptoms of the patients were alleviated. CONCLUSIONS The course of GAD 65 antibody-associated encephalitis is longer than other autoimmune encephalitides. The clinical symptoms of GAD 65 autoimmune encephalitis mainly manifested as chronic epilepsy, cerebellar ataxia, stiff-person syndrome, and limbic encephalitis, and combined with or without thyroid autoimmune diseases, type 1 diabetes, and thymoma. A comprehensive understanding of the disease is a way to prevent misdiagnosis and delayed treatment.
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Affiliation(s)
- Fei Zhu
- Department of Neurology Beijing Tiantan Hospital Capital Medical University Beijing China
- China National Clinical Research Center for Neurological Diseases Beijing China
| | - Wei Shan
- Department of Neurology Beijing Tiantan Hospital Capital Medical University Beijing China
- China National Clinical Research Center for Neurological Diseases Beijing China
- Beijing Institute for Brain Disorders Beijing China
| | - Ruijuan Lv
- Department of Neurology Beijing Tiantan Hospital Capital Medical University Beijing China
- China National Clinical Research Center for Neurological Diseases Beijing China
| | - Zhimei Li
- Department of Neurology Beijing Tiantan Hospital Capital Medical University Beijing China
- China National Clinical Research Center for Neurological Diseases Beijing China
| | - Qun Wang
- Department of Neurology Beijing Tiantan Hospital Capital Medical University Beijing China
- China National Clinical Research Center for Neurological Diseases Beijing China
- Beijing Institute for Brain Disorders Beijing China
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15
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Zhang YF, Yu N, Lin XJ, Wang L, Shi J, Zhang QQ, Di Q. Clinical characteristics and outcomes of autoimmune encephalitis patients associated with anti-glutamate decarboxylase antibody 65. Clin Neurol Neurosurg 2020; 196:106082. [PMID: 32682224 DOI: 10.1016/j.clineuro.2020.106082] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 05/16/2020] [Accepted: 07/09/2020] [Indexed: 12/31/2022]
Abstract
OBJECTIVE This study was to investigate the clinical characteristics and prognosis of autoimmune encephalitis (AE) associated with anti-Glutamic Acid Decarboxylase 65 (GAD65). PATIENTS AND METHODS From Jan 2016 to Aug 2018, three patients diagnosed as anti-GAD65 AE in our hospital were retrospectively analyzed for their general demographic characteristics, clinical presentation, cerebrospinal fluid (CSF) cytology, brain imaging, EEG, treatment and prognosis. RESULTS We found that Anti-GAD65 AE may be more common in young and middle-aged women, with initial presentations of refractory status epilepticus or cognitive decline following the disease progresses, but with less psychiatric symptoms than other types of AEs. The abnormal signals of MRI may be obvious in bilateral frontal, temporal lobe and hippocampus. CONCLUSION The production of anti-GAD65 may have a certain latency period, and it is usually negative at the onset stage. More studies need to be performed on larger populations and further understand the potential mechanisms underlying the above clinical features of anti-GAD65 AE.
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Affiliation(s)
- Yan-Fang Zhang
- Department of Neurology, The Nanjing Brain Hospital Affiliated Nanjing Medical University, 210029, Nanjing, China
| | - Nian Yu
- Department of Neurology, The Nanjing Brain Hospital Affiliated Nanjing Medical University, 210029, Nanjing, China.
| | - Xing-Jian Lin
- Department of Neurology, The Nanjing Brain Hospital Affiliated Nanjing Medical University, 210029, Nanjing, China.
| | - Lingling Wang
- Department of Neurology, The Nanjing Brain Hospital Affiliated Nanjing Medical University, 210029, Nanjing, China
| | - Jingping Shi
- Department of Neurology, The Nanjing Brain Hospital Affiliated Nanjing Medical University, 210029, Nanjing, China
| | - Qiao-Quan Zhang
- Department of Pathology, The Nanjing Brain Hospital Affiliated Nanjing Medical University, 210029, Nanjing, China
| | - Qing Di
- Department of Neurology, The Nanjing Brain Hospital Affiliated Nanjing Medical University, 210029, Nanjing, China
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16
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Graus F, Saiz A, Dalmau J. GAD antibodies in neurological disorders — insights and challenges. Nat Rev Neurol 2020; 16:353-365. [DOI: 10.1038/s41582-020-0359-x] [Citation(s) in RCA: 75] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/03/2020] [Indexed: 01/07/2023]
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Thaler FS, Bangol B, Biljecki M, Havla J, Schumacher AM, Kümpfel T. Possible link of genetic variants to autoimmunity in GAD-antibody-associated neurological disorders. J Neurol Sci 2020; 413:116860. [PMID: 32388243 DOI: 10.1016/j.jns.2020.116860] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 04/07/2020] [Accepted: 04/26/2020] [Indexed: 12/31/2022]
Abstract
OBJECTIVE In patients with GAD-antibody (ab) associated neurological disorders coexistence of other autoimmune disorders is observed. METHODS In this exploratory study we analysed variations in 33 candidate genes involved in autoimmunity or representing immunological check-points using next-generation sequencing. We performed haplotype-analysis of HLA-DRB1 and HLA-DQB1. Additionally, we analysed levels of sFasL, IL10, and IL18 in serum of patients and healthy controls. RESULTS 19 patients (3 males, 16 females; mean age at onset: 46.4 years) with positive GAD-ab and the following neurological phenotypes were included: n = 8 cerebellar ataxia, n = 6 limbic encephalitis, n = 4 stiff person syndrome, n = 1 demyelinating CNS disease with recurrent optic neuritis. 15 patients exhibited at least one other autoimmune disorder and/or showed other auto-ab. We identified several variations in genes linked to autoimmunity or representing check-point proteins. Most frequently (14/19 patients, allele frequency: 42.1%), we observed an amino acid exchange in the cytotoxic T-lymphocyte-associated protein 4 (CTLA4) gene. Two of the observed variants are known to cause alterations of protein function (Y446C in caspase-10, K750N in protein-tyrosin-phosphatase, non-receptor type 22). These latter variants were detected in two related patients (mother and daughter) who both present with GAD-ab-associated neurological disorders but with different clinical phenotypes. The rare haplotype DRB1*15:01:01 ~ DQA1*01:02:01 ~ DQB1*05:02:01 previously described in patients with GAD-ab-associated neurological disorders was not observed in any of our patients. No elevated serum levels of sFasL, IL18 or IL10 were observed in patients indicating no typical phenotype of autoimmune lymphoproliferate syndrome. CONCLUSIONS These findings suggest genetic risk factors in patients with GAD-ab-associated neurological disorders.
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Affiliation(s)
- Franziska S Thaler
- Institute of Clinical Neuroimmunology, University Hospital and Biomedical Center, Ludwig-Maximilians University Munich, Munich, Germany.
| | - Barbara Bangol
- Center for Human Genetics and Laboratory Diagnostics, Martinsried, Germany
| | - Michelle Biljecki
- Institute of Clinical Neuroimmunology, University Hospital and Biomedical Center, Ludwig-Maximilians University Munich, Munich, Germany
| | - Joachim Havla
- Institute of Clinical Neuroimmunology, University Hospital and Biomedical Center, Ludwig-Maximilians University Munich, Munich, Germany
| | - Adrian-Minh Schumacher
- Institute of Clinical Neuroimmunology, University Hospital and Biomedical Center, Ludwig-Maximilians University Munich, Munich, Germany
| | - Tania Kümpfel
- Institute of Clinical Neuroimmunology, University Hospital and Biomedical Center, Ludwig-Maximilians University Munich, Munich, Germany
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18
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Immune-mediated epilepsy with GAD65 antibodies. J Neuroimmunol 2020; 341:577189. [PMID: 32087461 DOI: 10.1016/j.jneuroim.2020.577189] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Revised: 02/11/2020] [Accepted: 02/11/2020] [Indexed: 12/18/2022]
Abstract
Anti-GAD65 antibodies have been identified in both acute/subacute seizures (limbic encephalitis and extralimbic encephalitis) and chronic isolated epilepsy. The evidence of high serum titers and intrathecal synthesis play a fundamental role in diagnosis but poorly correlate with disease severity or response to therapies. It remains controversial whether anti-GAD65 Abs are the pathogenic entity or only serve as a surrogate marker for autoimmune disorders mediated by cytotoxic T cells. Unlike other immune-mediated epilepsy, although multiple combinations of therapeutics are used, the efficacy and prognosis of patients with GAD65-epilepsy patients are poor. Besides, GAD65-epilepsy is more prone to relapse and potentially evolve into a more widespread CNS inflammatory disorder. This article reviews the recent advances of GAD65-epilepsy, focusing on the diagnosis, epidemiology, pathophysiology, clinical features, and treatment, to better promote the recognition and provide proper therapy for this condition.
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Lee YY, Chen IW, Chen ST, Wang CC. Association of stiff-person syndrome with autoimmune endocrine diseases. World J Clin Cases 2019; 7:2942-2952. [PMID: 31624742 PMCID: PMC6795735 DOI: 10.12998/wjcc.v7.i19.2942] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 08/14/2019] [Accepted: 08/26/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Stiff-person syndrome (SPS) and its subtype, stiff limb syndrome (SLS), are rare neurological disorders characterized by progressive muscular rigidity and spasms. Glutamic acid decarboxylase (GAD) is the enzyme that catalyzes the production of γ-aminobutyric acid (GABA), a major inhibitory neurotransmitter of the central nervous system. SPS is an autoimmune disease triggered by anti-glutamic acid decarboxylase antibody (anti-GAD Ab). Clinically, anti-GAD Ab is associated with SPS, type 1 diabetes mellitus (T1DM), and other autoimmune diseases.
AIM To investigate the link of autoimmune endocrine disorders with anti-GAD Ab in SPS subjects.
METHODS This retrospective study was approved by the Institutional Review Board of Chang Gung Memorial Hospital, Taiwan. We collected the patients with SPS from January 2001 to June 2018. By reviewing 14 patients from medical records, we analyzed the clinical findings with coexisting autoimmune diseases, particularly diabetes mellitus and thyroid disease, which are associated with anti-GAD antibody titers or other immunological test results (anti-thyroid peroxidase and anti-nuclear antibodies). We also evaluated malignancies, major complications, and reported treatment to improve symptoms. Anti-GAD antibodies were measured using radioimmunoassay and enzyme-linked immunosorbent assay (ELISA). The cut-off values of these tests are < 1 U/mL and < 5 U/mL, respectively.
RESULTS The median age of all patients was 39.3 (range, 28.0-54.0) years with a median follow-up period of 6.0 (2.7-13.3) years. Five (35.7%) patients were female; twelve (85.7%) were diagnosed with classic SPS and two (14.3%) with SLS. The median age of onset of symptoms was 35.0 (26.0-56.0) years with a median follow-up duration of 9.0 (2.1-14.9) years in the classic SPS group; the SLS group had a median age of onset of 46.7 years and a shorter follow-up duration of 4.3 years. Among nine classic SPS patients who underwent the anti-GAD Ab test, three were anti-GAD Ab seropositive and each of these three patients also had T1DM, latent autoimmune diabetes in adults, and autoimmune thyroid disease, respectively. In contrast, other rare autoimmune diseases co-existed in six anti-GAD Ab seronegative SPS patients. None of the SLS patients had additional autoimmune diseases.
CONCLUSION While typical clinical symptoms are crucial for the diagnosis of SPS, the presence of anti-GAD autoantibody may consolidate the diagnosis and predict the association with other autoimmune diseases.
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Affiliation(s)
- Yi-Yin Lee
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Chang Gung Memorial Hospital, Taoyuan City 333, Taiwan
| | - I-Wen Chen
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Chang Gung Memorial Hospital, Taoyuan City 333, Taiwan
| | - Szu-Tah Chen
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Chang Gung Memorial Hospital, Taoyuan City 333, Taiwan
| | - Chih-Ching Wang
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Chang Gung Memorial Hospital, Taoyuan City 333, Taiwan
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Manto M, Mitoma H, Hampe CS. Anti-GAD Antibodies and the Cerebellum: Where Do We Stand? THE CEREBELLUM 2019; 18:153-156. [PMID: 30343467 PMCID: PMC6443918 DOI: 10.1007/s12311-018-0986-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Anti-GAD65 antibodies (anti-GAD65 Abs) are associated with cerebellar ataxia (CA). The significance of anti-GAD65 Abs has been a focus of debates. Since GAD65 is intracellularly located and associated with type 1 diabetes mellitus and different clinical neurological phenotypes such as CA, stiff-person syndrome, and epilepsy, some researchers have argued that anti-GAD65 Abs have no pathogenic roles. On the other hand, recent physiological studies in vitro and in vivo have elucidated that binding of GAD65 by anti-GAD65 Abs elicits loss of GAD65 functions pertaining GABA release with an epitope dependence, leading to the development of CA. Internalization of autoantibodies has been also clarified. These studies provide substantial evidence of the pathogenesis of anti-GAD65 Abs in CA. We also discuss methodological problems in the identification of anti-GAD65 Abs.
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Affiliation(s)
- Mario Manto
- Service de Neurologie, Médiathèque Jean Jacquy, CHU-Charleroi, 6000, Charleroi, Belgium.,Service des Neurosciences, University of Mons, 7000, Mons, Belgium
| | - Hiroshi Mitoma
- Medical Education Promotion Center, Tokyo Medical University, Tokyo, Japan.
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Baizabal-Carvallo JF. The neurological syndromes associated with glutamic acid decarboxylase antibodies. J Autoimmun 2019; 101:35-47. [DOI: 10.1016/j.jaut.2019.04.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Revised: 04/07/2019] [Accepted: 04/08/2019] [Indexed: 12/12/2022]
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22
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Amanat M, Thijs RD, Salehi M, Sander JW. Seizures as a clinical manifestation in somatic autoimmune disorders. Seizure 2019; 64:59-64. [DOI: 10.1016/j.seizure.2018.11.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2018] [Revised: 11/10/2018] [Accepted: 11/22/2018] [Indexed: 02/07/2023] Open
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